|Year : 2015 | Volume
| Issue : 2 | Page : 118-123
Preventive measures for the transmission control of influenza in primary schools in Saudi Arabia: Lessons from the recent H1N1 pandemic
Rasha H Al Sheikh1, Manal R Koura1, Obeid O Al Treifi2
1 Department of Family and Community Medicine, College of Medicine, University of Dammam, Dammam, Kingdom of Saudi Arabia
2 Department of Medical Microbiology, College of Medicine, University of Dammam, Dammam, Kingdom of Saudi Arabia
|Date of Web Publication||6-May-2015|
Rasha H Al Sheikh
P.O. Box 321, Dammam 31411
Kingdom of Saudi Arabia
Background and Objectives: All over the world schools play an important role in the transmission of influenza within the community. The aim of the present study was to assess the preventive measures taken by primary schools in the Eastern province of Saudi Arabia, to reduce the transmission of H1N1 influenza.
Materials and Methods: A cross-sectional study was conducted in ten female primary schools selected by a multistage stratified random sampling technique with proportionate allocation out of 163 public and private schools in Dammam and Khobar. All ten schools were assessed for availability of human and nonhuman resources for the prevention of H1N1 transmission, and the efficiency of preventive measures by a predesigned checklist based on the guidelines of World Health Organization, Centre for Disease Control and Prevention and Saudi Ministry of Health and by the review of school records. Two classes were randomly selected from each school for the screening of desks for influenza by rapid antigen test and confirmation of positive cases by polymerase chain reaction. The total sample size was 500 desks.
Results: Optimal implementation of recommended preventive and control measures in the primary schools was observed. All desk swab samples were negative for the influenza virus. Despite the low prevalence of students immunized with the H1N1 vaccine (2.3%), the percentage of suspected and confirmed H1N1 cases was low (0.6% and 0.1% respectively).
Conclusion and Recommendation: Appropriate implementation of the recommended preventive and control measures for influenza in primary schools may reduce H1NI viral transmission even without mass student immunization. Accordingly, it is recommended that only high-risk children be immunized to reduce the incidence of side-effects of the vaccine.
ملخص البحث :
هدفت هذه الدراسة المقطعية إلى تقييم التدابير الوقائية في المدارس الابتدائية للحد من انتشار العدوى بأنفلونزا 1H1N في المنطقة الشرقية من المملكة العربية السعودية. وشملت عشرة مدارس ابتدائية للبنات خاصة وحكومية في مدينتي الدمام والخبر. تم تقييم المدارس حسب توفر الموارد البشرية وغيرها وتقييم الإجراءات الوقائية طبقًا لتوجيهات منظمة الصحة العالمية وتوصيات وزارة الصحة السعودية. أظهرت الدراسة أن هناك تطبيق جيد لتوصيات الوقاية اللازمة ضد الأنفلونزا في المدارس. وخلصت الدراسة إلى أن تطبيق التوجيهات اللازمة للوقاية من الأنفلونزا يقي من انتشار عدوى أنفلونزا الخنازير، حتى وإن لم يتم تحصين الطلاب ضد أنفلونزا 1H1N. وبذلك يوصى أن يقتصر التحصين على الفئة الأكثر تعرضًا للإصابة وذلك للحد من حدوث الأعراض الجانبية للتحصين.
Keywords: H1N1 prevention, influenza, primary schools, rapid antigen test
|How to cite this article:|
Al Sheikh RH, Koura MR, Al Treifi OO. Preventive measures for the transmission control of influenza in primary schools in Saudi Arabia: Lessons from the recent H1N1 pandemic. Saudi J Med Med Sci 2015;3:118-23
|How to cite this URL:|
Al Sheikh RH, Koura MR, Al Treifi OO. Preventive measures for the transmission control of influenza in primary schools in Saudi Arabia: Lessons from the recent H1N1 pandemic. Saudi J Med Med Sci [serial online] 2015 [cited 2022 Jan 28];3:118-23. Available from: https://www.sjmms.net/text.asp?2015/3/2/118/156417
| Introduction|| |
Because of major current ecological changes, emerging viruses pose a constant threat to human health.  Besides, the annual Islamic pilgrimage to the city of Makkah that brings large numbers of people to Saudi Arabia is a constant source of concern for public health officials because of the increased risk for the spread of disease. Therefore, strategies for planning for pandemics should bear in mind the emerging risks posed by many influenza subtypes originating from a variety of sources.
The 2009 outbreak of the novel H1N1 influenza virus caused significant morbidity and mortality in schools and communities worldwide. According to the U.S. Centers for Disease Control and Prevention (CDC), the rate of infection in the US was highest in individuals aged 5-24 years.  According to the guidelines of Saudi Ministry of Education for the prevention and control of flu pandemics in schools, primary school children, especially those aged less than 12 years, are the most susceptible to influenza infections. 
Influenza-like illness (ILI) is defined as a fever of at least 38°C with a cough or a sore throat in the absence of a known cause other than influenza. An individual with ILI and laboratory-confirmed H1N1 influenza A virus (by real-time reverse transcriptase polymerase chain reaction [PCR] or culture) is confirmed to have pandemic H1N1 influenza A. Pandemic H1N1 influenza A may be suspected in an individual who does not meet criteria for confirmed H1N1 influenza A, but has an ILI and supporting epidemiology. 
The CDC has recommended prevention and control strategies for use in schools, to help prevent the transmission of influenza among students, teachers, and staff.  The World Health Organization (WHO) has also provided a framework for reducing the pandemic influenza transmission in school settings. This includes advance planning, implementing measures for reducing transmission, and assessing the need for class suspension and/or school closure.  In the Kingdom of Saudi Arabia, the Ministry of Health (MOH) and Ministry of Education (MOE) recommended procedures for school preparedness for effective influenza control. Beginning in the fall of 2009, two members of each school staff were given health education training and instructed to prepare an isolation room fully equipped with masks, gloves, a thermometer, temperature-lowering medications, hand sanitizers and record files. Teachers were instructed to send visibly symptomatic students to the clinic and isolation room and follow all policies for suspected cases. Students and teachers with fever were instructed to remain home until they were free of fever for at least 24 h, without the aid of temperature-lowering medications. In addition, the following preventive measures were implemented: A daily record of student and teacher absence; provision of materials that aid hygiene to students and teachers (water, soap, hand sanitizer, etc.); ensuring proper ventilation in the classrooms; frequent cleaning of surfaces with detergents; frequent replacement of cleaning materials (rags, mops, etc.); maintenance of a minimum distance of 1 m between desks; increasing student awareness of H1N1 and methods of its prevention; encouraging parents to notify the school of a child's illness; educating school staff on pandemic influenza by the use of the Saudi MOH website; and regular communication between schools and the MOE and MOH. 
The CDC recommended a prioritized list of recipients for the pandemic H1N1 vaccine: Pregnant women, household contacts, healthcare personnel, individuals aged 6 months to 24 years, individuals aged 65 years and above, and individuals aged 24-64 years with health conditions associated with high-risk influenza complications, such as chronic pulmonary disease, cardiovascular disease (except isolated hypertension), active malignancy, chronic renal insufficiency, chronic liver disease, Diabetes mellitus, Hemoglobinopathies (e.g., sickle cell disease), immunosuppression, any condition that can compromise the handling of respiratory secretions (e.g., cognitive dysfunction, seizure disorders) and long-term aspirin therapy which might increase Reye syndrome after an infection with influenza virus. 
In October 2009, before the Hajj season, the Saudi MOH supplied H1N1 vaccine (Pandemrix) to Mecca and Madinah residents, and to people at high-risk for H1N1 influenza complications. Simultaneously, the MOH highly recommended and encouraged parents to vaccinate their children to prevent the spread of H1N1 infection in schools. 
The aim of the present study was to assess the preventive measures taken by primary schools in the Eastern province to reduce the transmission of H1N1 influenza. The null hypothesis was a low level of preventive and control measures.
| Materials AND METHODS|| |
A cross-sectional study was conducted after approval by the MOE, in ten female primary schools selected by multistage stratified random sampling technique using computerized random sampling software (research randomizer) with proportionate allocation out of 163 public and private schools in Dammam and Al Khobar, Eastern Saudi Arabia [Table 1].
All ten schools were assessed for availability of human and nonhuman resources for the prevention of H1N1 transmission, and efficiency of preventive measures by means of a predesigned checklist based on guidelines from WHO, CDC and the Saudi Ministry of Health, and by reviewing school records.
According to the MOE, 46,884 female students were enrolled in the primary schools of Dammam and Khobar in the academic year 2009-2010. The minimum sample size for screening of students' desks for contamination with influenza A or B was calculated by Epi Info TM Version 6 statistical package at an expected rate of 10% ± 3% and 95% confidence level, and was found to be 381. Accordingly, two classes were randomly selected from each school (taking the average number of students in each class as 25) to give the total sample size of 500 desks.
A professional nurse, well-trained in infection control collected the specimens during the month of January 2010 using ∑-Virocult ® swabs [Medical Wire, [Figure 1]a at the end of the school day. To screen student desks for the influenza A or B virus, we used a rapid antigen test (RAT), (TRU FLU ® , Meridian Bioscience Inc., the kit contains 32 tests which is a 15-minute assay for the detection and differentiation of influenza A and influenza B.). Its sensitivity was 87.2% to influenza A and 63.6% to influenza B, and its specificity 89.3% for influenza A and 99.4% for B in a fresh sample. In a frozen swab, sensitivity to influenza A was 85% and 50% to influenza B virus, and its specificity was 93% for A and 100% for B. The surfaces and edges of each desk were swabbed after they were dampened with normal sterile saline. Swab samples were transported via a cooler at 4°C and stored at -70°C in a freezer at the microbiology lab in Dammam University for testing. Positive RAT results for influenza should be confirmed by PCR with the Artus Infl/H1 LC/RG RT-PCR kit ready-to-use systems for the detection of influenza A viral RNA and RT-PCR on instruments. The kit contained an H1N1 influenza A-specific detection reagent of the 2009 pandemic H1N1 virus.
|Figure 1: Rapid antigen test for influenza A and B (a) Viral swab samples were transported using Σ-Virocult®, which combines Sigma- Swab® with Σ-Virocult® medium, and is compatible with new molecular techniques, including real-time polymerase chain reaction. (b) TRU FLU® rapid antigen test. A negative test for influenza A or B is indicated by the presence of a pink-red band at the control line position with no other visible bands.|
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| Results|| |
Screening of students' desks for contamination with influenza viruses showed that all 500 swabs were negative for influenza A and B [Figure 1]b]. Thus, no confirmation testing was necessary. School records reported an incidence rate of 0.1% of confirmed H1N1cases in primary school children (aged 5-14 years) in Khobar and Dammam [Table 2].
|Table 2: Preventive measures against H1N1 in primary|
schools of Damman and Khobar
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[Table 3] shows the availability of human resources for the prevention of H1N1 in primary schools. The health educator to student ratio was highest in private schools of Khobar and lowest in public schools of Khobar. The custodial staff to student ratio was highest in private schools in Dammam and lowest in the public schools of Khobar; indicating that private schools had better human resources, and that human resources were lowest in public schools in Khobar.
|Table 3: Human resources available for H1N1 prevention in primary schools of Dammam and Khobar|
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[Table 4] shows the availability of nonhuman resources for the prevention of H1N1. The classrooms of public schools were bigger than those of the private schools. The crowding index (students/m 2 ) was highest in Dammam public schools and lowest in Khobar schools, but still less than 1/m 2 in all schools. All school desks were made of fiber glass except for one public school in Dammam which had wooden desks. The door handles/opening mechanisms were similar in all schools, except for one public school in Khobar, which had a push metal door-opening mechanism. The sizes and number of classroom windows were greater in public schools than in private schools because of the larger size of the class rooms. Educational materials were adequate in all schools. All schools had an isolation room/clinic which was fully equipped with masks, gloves, tissue paper, hand sanitizer, a thermometer, and medications like antipyretics with the exception of one public school in Dammam which had no medications. The availability of sanitary materials (e.g., hand sanitizers, boxes of tissues, and garbage baskets) was adequate in all schools except for the Dammam public schools, which had insufficient number of boxes of tissue and waste baskets. The toilet conditions (cleanliness; in working order; water supply; and availability of soap, hand sanitizers, paper towel, and bins) were adequate in the private schools of Dammam and Khobar, but inadequate in the public schools of Dammam.
|Table 4: Nonhuman resources available for H1N1 prevention in primary schools of Damman and Khobar|
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[Table 2] lists primary school preventive measures and recorded cases of influenza. It was found that more than eleven health education sessions were conducted in schools. Student's absence due to fever or any other illness was 4.5% of the days. The percentage of primary students with suspected (0.6%) or confirmed (0.1%) influenza cases was low. The percentage of students who had received the H1N1 vaccine was low as well (2.3%); the rate was lower in Khobar schools than in the Dammam schools.
Desks in all schools were arranged in the shape of a C or in groups, and the distance between desks was inadequate, except for one private school in Dammam, which maintained a distance of one meter between every two desks. Computers and telephones were available in all schools, but two public schools in Dammam lacked internet connection. Communications with the MOE and MOH were similarly conducted in all schools. Notification policies, sick-leave procedures, isolation, and absences were correctly reported in all schools, but most public schools of Dammam and Khobar had no alternative procedures for teaching (e.g., home visits or online learning) during school closures.
In general, public and private primary schools of Dammam and Khobar were adequately prepared for prevention of the transmission of H1N1 influenza.
| Discussion|| |
The present study showed that the reported days of primary students' absence due to fever or any illness were only 4.5%. The reported incidence rate of suspected cases of influenza was 0.6%, and only 0.1% for confirmed H1N1 cases in spite of the low immunization coverage with H1N1 vaccine (2.3%). Moreover, all desk surfaces screened by RAT for influenza A or B viruses were negative. However, the H1N1 screening test (TRU FLU ® ) using frozen swabs as used in this study had a sensitivity of 85% and a specificity of 93% for influenza A virus. This could have yielded some false-negative results.
In comparison, sero-epidemiological studies of pandemic H1N1 influenza A 2009 virus infections among primary school children prior to vaccination showed a wide range of cumulative incidence. It was 4.9% in Norway, 9.8% in Australia, 20-26.7% in India, 42% in England and 43.4% in Hong Kong. ,
The low vaccination coverage of school students may be explained by concerns and debates of parents as well as decision makers, regarding the use of H1N1 vaccine This was prompted by the lack of information of the efficacy of the new vaccine, its side effects, and complications such as Guillain-Barre syndrome (GBS), because of the brevity of the time for clinical trials used to prove the safety of the vaccine. The Pandemrix vaccine used in Saudi Arabia was a multi-dose vaccine including thiomersal preservative and adjuvant, while in USA the single nonadjuvant vaccine was used. Studies have shown that there should be caution in vaccinating certain individuals, particularly those with a history of GBS. , On the other hand, contracting influenza greatly increases an individual's risk of developing GBS (approximately 10 times according to recent estimates) which the influenza vaccination provides some protection against. ,
The present study revealed that primary schools in Dammam and Khobar properly implemented the preventive and control measures against the transmission of influenza recommended by WHO, CDC and MOH with the following parameters: Health educator to student ratio, custodial staff to student ratio, availability of fully equipped isolation rooms/clinics, status of hygiene of classrooms and toilets, availability of cleaning materials (soap, water, etc.), availability of communication tools (computers, telephone, internet, etc.), sound notification, sick-leave procedures, isolation, and absence policies. In addition, more than eleven health education sessions were conducted in schools, which might explain the fact that about 60% of primary female students in Dammam area had good knowledge of H1N1, its mode of transmission and prevention. 
| Conclusion|| |
The low percentage of suspected and confirmed H1N1 cases together with the absence of influenza virus on student desks in the studied schools, despite the low vaccination coverage, indicated that compliance with proper preventive and control measures for pandemic H1N1 in primary schools may reduce transmission even in the absence of mass student immunization for H1N1. Therefore, immunization could be restricted to high-risk groups like asthmatics, diabetics, children with sickle cell anemia or immuno-compromised children to reduce the incidence of side effects of the vaccine.
| Acknowledgment|| |
We thank King Abdulaziz City for Science and Technology (KACST) for funding our research.
We also thank the Microbiology team members in the College of Medicne at University of Dammam for their help in conducting the H1N1 screening tests.
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[Table 1], [Table 2], [Table 3], [Table 4]